OVERVIEW: What every practitioner needs to know

Suicidal ideation is common in children and adolescents and in and of itself does not indicate a high risk for suicide. A suicide attempt, on the other hand, is a relatively rare and serious event that requires a thorough psychiatric evaluation. While suicidal ideation does not indicate a higher risk for psychopathology, a suicide attempt carries a higher likelihood that the person has a co-occurring psychiatric diagnosis and requires treatment. In the United States, there are approximately 4,000 completed adolescent suicides each year, approximately 2 million attempted adolescent suicides each year, and almost 700,000 adolescents who present for medical attention. Most adolescents who commit suicide (greater than 90%) suffer from a psychiatric disorder at the time of their death, and more than half had suffered from a psychiatric disorder for more than 2 years.

What immediate measures should be taken when a child or adolescent comes into the emergency room following a suicide attempt?

Be sure that the patient is properly supervised. A child or adolescent who made a recent attempt requires 1:1 supervision until the evaluation is completed and the child is either admitted to a psychiatric facility or discharged to home.

Be sure that the room is free from dangerous itemsor monitor the patient closely for the risk areas in the room. This can include any items that can be used to cause self-injury such as open windows, sphygmomanometers, items with sharp edges, glass items (television screens), items that can be used for hanging (sheets, clothing, etc.) and anything that could be used to tie a ligature for hanging (toilets, shower heads, beds, under beds on the springs, IV poles, etc.). The room should also be cleared of any object that can injure others.

Do not use a “no-suicide contract” or “contract for safety.” There is no evidence to support the efficacy of these types of contracts, which state that the child or adolescent agrees not to engage in self-harming behavior and to tell an adult if he/she is having suicidal urges. First, the child or adolescent might not be in a mental state to accept or understand the contract. Second, a contract might inadvertently be harmful by giving the family and/or practitioner a false sense of security and lead to a decrease in supervision vigilance.

What elements are essential in a Child and Adolescent Suicide Assessment?

It is imperative that a thorough psychiatric evaluation, performed by a qualified mental health professional, is completed prior to discharge from an emergency room or hospital for any child who has made a suicide attempt.

A suicide assessment of a child or adolescent requires collateral contact with at least one of the following: parent/guardian, therapist, school, or other persons who may be close to the child and aware of his/her suicidal thoughts/actions.

Suicide risk should be based on the child’s understanding of the lethality of their act, not on the actual lethality. Some children are not at a developmental stage to understand the irreversibility of death, or some may engage in dangerous actions thinking that they can be undone at a later time. This developmental understanding of how a child understands death is an essential perspective for the evaluation. Even though the method may be of a low lethality risk, if the child believed it would kill him/her, it indicates a higher risk than if they recognized it was a low lethality attempt. On the other hand, someone who performs a high lethality act that they did not believe to be lethal, needs to be considered high-risk as well. For example, an adolescent who says, “I just thought that by taking 30 acetaminophen tablets I would get rid of my headache faster” or “I thought if I took 20 diphenhydramine, it would just help me to sleep better,” needs further evaluation.

A psychiatric assessment should be conducted by a clinician with expertise in child and adolescent mental health. If such a person is not available, then you will need to determine whether the child should be transferred to a facility for a psychiatric evaluation.

The following is a list of factors to identify children or adolescent suicide attempters who are at greatest risk for eventual completed suicide. Do not discharge a patient with any of the features in the list below without a complete psychiatric evaluation, as they are predictive of future suicidal behavior.

Suicidal History

Still thinking of suicide

Have made a prior suicide attempt

Method other than ingestion or superficial cutting

Medically serious attempt

Took steps to prevent discovery

Family history of suicide or recent exposure to suicide in friend or family member

Demographics

Males are at greater risk for suicide completion than females. In particular, male suicide attempters with the following characteristics should not be discharged.

Depression or other mood disorder

Alcohol or other drug use disorder especially in conjunction with a mood disorder

Aggressive or disruptive behavior

16 years or older

Previous suicide attempt

Females at greater risk include the following:

Panic attacks

Depression or other mood disorder

Previous suicide attempt

Risk factors for both males and females include the following:

Chronic bullying and/or victimization

Gay, Lesbian, Bisexual, and Transgender Youth- These adolescents have increased risk for suicidal thoughts and attempts (increased risk of 2- to7-fold) and carry other risk factors such as high rates of drug/alcohol use and chronic bullying and victimization.

History of abuse

Poorer chaotic social supports- including but not limited to an inability to develop trusting relationships with medical clinicians or mental health workers and/or a recent disruption in an important relationship (romantic, family, therapist, physician, friendship, etc.). This also includes the lack of ability to trust a responsible adult who could assist with safety planning.

Mental State

Depressed, manic, hypomanic, severely anxious, or a mixture of these states

If you decide to allow the patient to leave following an evaluation, it is important to always do the following:

Check that firearms and lethal medications are effectively secured or removed from the home. The use of a firearm is the most common method of completed suicide in the United States, and ingestion of medication is the most common method of attempted suicide. Therefore, all evaluations must include learning about the availability and presence in the home of firearms and lethal medication. Parents/guardians must be explicitly told to remove firearms or other suicide means (medications) from the home.

Remind parents about the disinhibiting effects of alcohol and other drugs.

Check that there is a person at home that the patient feels is supportive and confirm the amount of his/her availability.

Check that a follow-up appointment has been scheduled with a current treatment provider, a new provider, in-home treatment service or partial hospitalization program.

Remember that treatment recommendations will be more likely to be followed if they match the family’s expectations, are economically feasible, and if the parent is well and available to support attendance at appointments. Be sure to spend time with parents explaining the importance of following through with all sessions.

How can I appropriately ask a child or adolescent about suicidal ideation or a recent suicide attempt?

The most important thing to do when discussing suicidal ideation and assessing the risk for a future suicide attempt, is to be straightforward and ask direct questions. People often mistakenly believe that asking a child if they are suicidal or encouraging them to give you details as to how they would attempt suicide will actually cause the child to have increased suicidal thoughts or behaviors. In fact, a recent multi-site study looked at predictors of suicidal adverse events in a population of depressed adolescents and found that relying on “spontaneous report of suicidal adverse events will underestimate the rate of events compared to systematic assessment” (Brent, et al., 2009). In other words, waiting for the child to spontaneously talk about their intentions could cause you to miss serious risks.

Keep in mind that the goal of your questions is to determine whether the child or adolescent is contemplating suicide or attempted suicide without anyone’s knowledge. Also, take into account the child’s developmental understanding of death. Some key questions can include, but are not limited to the following:

Do you wish that your attempt had led to your death? (i.e., is there remorse about the attempt or that the suicide was not completed?)

Do you feel so upset that you wish you were not alive or were never born?

When you hurt yourself, did you believe that you could hurt yourself or kill yourself by doing it?

Have you ever hurt yourself or tried to hurt yourself in the past?

Did you ever try to kill yourself before?

Are you currently thinking about wanting to hurt yourself? If so, what are your thoughts? How often do you have these thoughts? Have they increased in intensity or frequency recently? How strong is your urge? Can you control these thoughts (i.e., are they obsessive or psychotic in quality)?

Do you have a plan for how you would hurt yourself? If so, can you describe what you would do? What is the plan? What would you use? Would anyone be able to find you or save you? Do you think it would work? Where and when would you do it?

What, if anything, keeps you from acting on your urge?

Do you have access to [the means] available to you? How easy or hard would it be for you to get it?

What caused this disease to develop at this time?

Stressful life event: such events can be relatively minor such as getting into trouble at school or with law enforcement, breakup with a significant other, a fight among family or friends, or recent significant loss can be a precipitating factor in adolescents who are already at risk by virtue of their psychiatric condition.

Media: a news story of another person’s suicide or reading about or viewing a suicide portrayed in a romantic light in a book, magazine, or newspaper, can increase the risk of suicide in an adolescent. Also, if there was a recent suicide in the child’s community or family that led to significant fanfare and attention, there is risk for “copy cat” suicides.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

There are no laboratory tests that can be utilized to determine risk for suicide.

If you believe that the patient has had a recent ingestion, you would follow the protocol for such an evaluation, including toxicology screening for aspirin and acetaminophen, and a quantitative drug and alcohol screening.

A quantitative drug and alcohol screening is useful for all suicide attempters for risk stratification- because substance abuse with a mood disorder increases the risk for future completed suicide.

If the patient had access to any medications that require blood levels to be checked, these should be checked as well (i.e. lithium, divalproate sodium, carbamazepine, etc.).

If the attempter is a female, a pregnancy test would be useful in the case that she will be recommended to commence medication management for an underlying psychiatric condition

Because children and adolescents with suicide attempts often have underlying psychiatric disorders, baseline laboratory studies can be helpful, because some psychiatric disorders will likely require medications, some of which can have metabolic side effects. You could consider checking the following: CBC, LFT’s, Chem-7, TSH, and a lipid panel.

Would imaging studies be helpful? If so, which ones?

There are no imaging studies that can be utilized to determine risk for suicide.

How do suicides occur and how can they be prevented?

Factors Mediating or Facilitating Suicide Risk in Children and Adolescents

If you are able to confirm that the patient has attempted or might attempt suicide, what treatment should be initiated?

How do you determine the appropriate level of care for your patient?

There are various levels of psychiatric care available for children with psychiatric disorders ranging from inpatient care (staying in a psychiatric hospital) to different levels of outpatient care (partial, in-home, outpatient). Although the availability of each of these services varies regionally, the following represents the ideal options for mental health care for these children. Safety considerations should drive decisions regarding the level of care although at times, availability may be a factor in the decision-making.

Inpatient psychiatrichospitalization:

Inpatient psychiatric hospitalization offers intensive multidisciplinary treatment to children and families in a safe and secure environment. The inpatient setting has 24-hour nursing care and round-the-clock observation. There is usually a combination of the following services: psychiatric assessment and diagnosis, individual therapy, group therapy with focus on coping skills development, milieu therapy, medication evaluation, and nursing assessment and care.

If you decide to admit a child for a psychiatric hospitalization, they can be admitted voluntarily or involuntarily. The children who agree to the hospitalization and also have a parent/guardian who agrees may be admitted voluntarily. If the child does not agree and/or a parent or guardian is unavailable or disagrees with the plan for admission, the patient will be admitted involuntarily. The process for involuntary psychiatric admissions varies by state but most require that the child is at imminent risk of injury to themselves or others to meet the standard. In addition, the legal rights of the child and family are delineated in the mental health law and may vary by state.

Although there have been no randomized controlled trials to determine whether hospitalizing high risk suicide attempters saves lives, you should be prepared to psychiatricallyadmit suicide attempters who meet the high risk criteria delineated above.

Partial hospitalization:

This modality of treatment offers intensive multidisciplinary treatments and skilled observation and support, similar to an inpatient setting, but in an outpatient setting. Partial hospitalization programs are typically for 4-6 hours per day, and they are a good option for patients who are disturbed but determined to be safe to return home or to another living arrangement (residential program, group home, etc.). These programs will address the psychiatric conditions and psychosocial stressors that led to the attempt. This can be used as a diversion from inpatient hospitalization or following an inpatient psychiatric hospital stay as a step-down prior to outpatient treatment.

Intensive Home-Based Treatment:

There are a variety of home-based treatments that may be appropriate following a suicide attempt. These treatments address the psychiatric condition and focus on the underlying psychosocial stressors. These sessions are more frequent than outpatient care but not usually as time intensive as partial hospitalization. If one of the central triggers for the patient is disturbed family interactions, this allows a treatment provider to be present in the home where these interactions occur. These providers can be present for several hours per week (3-20 hours) depending on the particular services available in your area. In addition, for some children/families an Intensive Outpatient Program (IOP) may be necessary and this could include several hours per week of treatment from a therapist with psychiatric evaluation and medication management as well.

Outpatient Treatment:

Outpatient treatment should be used when the adolescent is not likely to act on suicidal impulses, there is adequate support and supervision at home, and there is someone available to take action if the adolescent’s behavior or mood deteriorates. There are a variety of mental health providers that work with children and adolescents including child & adolescent psychiatrists, child psychologists (Ph.D./Psy.D), social workers (LICSW, LCSW), and licensed mental health counselors (LMHC). There may be limited availability of these providers in your area and it is best to work with the child’s insurance company to secure appropriate care. Often, insurance companies have Care Managers who can assist with facilitating treatment for at risk children.

What is known about medication management for suicidal adolescents?

Studies have indicated that selective serotonin reuptake inhibitors (SSRIs) are safe and effective in the treatment of adolescent depression. Antidepressants in combination with therapy for depressed adolescents have been found to be most effective in reducing suicidal ideation in children and adolescents. Because SSRIs are more effective than tricyclic antidepressants in placebo-controlled trials, these medications are the first-line medication choice for suicidal depressed children and adolescents. In addition, while tricyclic antidepressants can be lethal in overdose, SSRIs have a low lethal potential. Currently, fluoxetine is the best studied SSRI for children and adolescents and can be considered the first treatment option within that category of medication.

Although there have been some questions about increased risk of suicidal ideation and behavior in adolescents taking SSRIs, the conclusions of studies have shown that although suicidal ideation may be higher than that found with placebo, it is no more common in adolescents taking SSRIs than would be expected in a depressed population. However, there might be a relationship between akathisia from SSRI treatment and suicidality. Clinicians should closely monitor children during the early stages of fluoxetine treatment for increased suicidality and akathisia.

Other medication considerations include the following:

1. Be cautious about medications that might be disinhibiting in children such as benzodiazepines and phenobarbital.

2. Be cautious about prescribing medication with high lethal potential in overdose such as phenobarbital and tricyclic antidepressants.

3. In a patient at risk for suicide, it is important to treat their ADHD symptoms. In fact, it is safe and recommended to prescribe stimulants to children and adolescents with ADHD to minimize impulsivity which can increase their risk for suicide attempts.

4. Lithium or another mood stabilizer are first line pharmacological treatments for children and adolescents with bipolar disorder and should be prescribed before an antidepressant.

5. Always engage a parent or guardian for administration of medications and monitoring unexpected changes of mood, agitation, or unwanted side effects when starting a new medication.

What is the risk that a child or adolescent who makes a suicide attempt will have a completed suicide?

There may be an increased representation of bipolar disorder, firearms in the home, high suicidal intent, or combinations of mood and nonmood disorders (Brent et al., 1988) in those who have completed suicides. A psychological autopsy completed by Gould et al. (1996) revealed that psychosocial factors increase the risk of suicide beyond the level attributable to psychiatric illness. The risks that they found include: school problems, family history of suicide, poor parent-child communication, and stressful life events.

It is difficult to study the differences between suicide attempters and completers. One factor making this difficult is that serious suicide attempters requiring inpatient care are unlikely to represent suicide attempters in general, and the former are the population utilized for comparison studies. There may be greater differences between less serious suicide attempters and suicide completers, but given that the former are less likely to receive medical or psychiatric attention, this study is more difficult to complete.

What causes this disease and how frequent is it?

What is known about the epidemiology of child and adolescent suicide? Is there a genetic vulnerability to suicide?

Epidemiology:

1. General: Approximately 4,000 adolescents commit suicide each year in the United States, and an estimated 500 suicide attempts are made for each completed suicide. Suicide is the 3rd most common cause of death for adolescents 15-24 years of age (behind accidents and homicide) and the fourth leading cause of death in pre-adolescents ages 10-14. According to the 2009 Youth Risk Behavior Survey (YRBS), which the CDC administers nationwide, 13.8% of high school students had seriously considered suicide in the prior 12 months, 10.9% had made a suicide plan, 6.3% had attempted suicide and 1.9% had made a suicide attempt that required medical attention.

2. Regional Variability: Suicide rates in the United States are highest in the western states and Alaska and lowest in the southern, north central, and northeastern states. The lowest rates for both African-American and white suicides is the Deep South and the Northeast. Due to strong firearm control laws, there is less likely to be a firearm suicide in the Northeastern United States than in other regions of the country. In rural areas with less stringent laws, it is more common. Jumping from a height is more prevalent in urban areas (due to presence of tall buildings); asphyxiation by carbon monoxide exhaust is more common in suburban areas (where there are garages and cars).

3. Method: Ingestions (most commonly over-the-counter analgesics), superficial cutting, hanging, shooting, jumping, stabbing, and drowning are the most common methods of attempt. However, the incidence of attempts by different methods is not well known due to variability in requiring medical attention. Ingestions account for 16% of female suicides (15-24 years) but only 2% of males of the same age.

4. Gender: Young males (ages 10-24) have a higher suicide rate than their female peers. The suicide rate for males is more than five times the rate of same age females. Rates of suicide decreased for young adult males (15-24) and all females (10-24) between 1981 and 2003 likely due to the introduction of SSRI’s. During this same time period, the rate increased from 1.2 to 1.7 per 100,000 for males 10-14. Females are more likely to report suicidal ideation and attempts than their male peers. In fact the suicide attempt rate is 1.6 females for each 1 male.

5. Ethnic: American Indian/Alaskan Native males have the highest suicide rate (2-4 times that of same-age males in other racial groups). Suicide is the second leading cause of death for American Indian adolescent and young adult males. The Surgeon General reported an increase in the suicide rate of 105% for African-American males (15-19 years old) between 1980-1996. While some research suggests this might be due to increased access to firearms, other research suggests that it is related to long-term depression and substance abuse, as with white youth. Black and Hispanic females are least likely to commit suicide.

6. Developmental: Younger children utilize less complex and more easily available means for their suicidal impulses. There is less discrepancy between suicidal ideators and attempters in young children. Both suicide ideation and attempts in prepubertal children predict suicide attempts in adolescence. Suicide attempts are associated with disturbed family relationships in prepubertal children as compared with peer conflicts in adolescents.

7. Lesbian, Gay and Bisexual (LGB): LGB youth of both sexes are more likely to experience suicidal thoughts and attempt suicide than heterosexual youth. The studies report an increased risk of 2- to 7-fold. These youth carry multiple risk factors for suicidal behavior including high rates of drug and alcohol use, chronic bullying, and victimization at school.

Genetic Risk:

After controlling for parental psychiatric disorders, adolescent suicide is five times more likely if someone’s mother died of suicide and two times as likely if the father died of suicide. There is a 25% concordance rate for monozygotic twins and 0% concordance rate for dizygotic twins in one study. While genetic polymorphisms confer risk for suicide, a stressor seems necessary for its expression. There are studies that have shown that a serotonin transporter with low expression correlates with suicide (5-HTTLPR- s allele). But this is likely one of several genes that contribute to such complex behavior. Genes associated with the hypothalamic-pituitary-adrenal (HPA) axis are also likely indicated in the manifestation of suicidal behavior. Overactivity of the HPA axis and alteration in gene neuropeptide systems secondary to abuse relate to suicidality in children and adolescents.

Are additional laboratory studies available; even some that are not widely available?

There are no laboratory studies available for suicide evaluation or prevention.

How can adolescent suicide be prevented?

Primary care physicians should utilize a screening tool or directly ask their patients about depression, suicidal preoccupations, and previous suicidal behavior. There is evidence that teenagers in their mid-to-late adolescence will reveal this information if asked directly. Those adolescents identified to be at risk should be referred for further evaluation and treatment, and if necessary, receive support and follow-up during the transition (via telephone, case manager, etc.).

Two tools readily available on the internet include the Pediatric Screening Checklist (PSC) for parents to complete and the self-report measure for children (Y-PSC). A screening tool for depression is the Patient Health Questionnaire-9 Modified (for adolescents).

Primary care physicians should be trained to recognize risk factors for suicide and suicidal behavior and refer patients to a mental health clinician.

Means restriction can be an important aspect to suicide prevention. By ensuring that youth do not have access to the most commonly used lethal methods of suicide, we can decrease the number of completed suicides (firearms, pesticides, medications, etc.). For example, reducing a young person’s access to firearms may result in a short-term reduction in the rates of suicide; there is not yet evidence that this has a permanent effect.

Gatekeepers are another group that could participate in early identification of adolescents at risk. Although this often refers to such groups as the military, it is possible that schools can perform such a function.

Public Health interventions have variable responses. Raising the minimum legal drinking age for young adults appears to reduce the suicide rate in the affected age group. Crisis Hotlines have failed to reduce the incidence of suicide by recent research standards. However, problems have been identified, and correcting the problems could increase the effectiveness.

Ongoing controversies regarding etiology, diagnosis, treatment

Due to the risks of research studies with suicidal patients, there are many questions that remain unanswered. Because of the difficulties in obtaining detailed data about completed suicides and suicide attempts, we are unable to differentiate between children and adolescents at risk of suicide completion compared with attempters.

Also, there is significant ongoing interest in suicide prevention as there is not yet an intervention that is proven to be effective.

Furthermore, youth suicide rates have fluctuated over time. There was a 300% increase in rates between the 1950’s and mid-1990’s, and then a decline until 2003. Although there are hypotheses about fluctuations in both directions, there is not consensus about the causes of these changes over time.